Three Year Cluster Action Plan 2018 - 2021 Penderi Cluster
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Welcome to the Penderi Three Year Cluster plan, 2018 – 2021
1. Penderi Cluster Overview
The Penderi Cluster Network is one of five clusters in Swansea, geographically covering Blaenymaes, Portmead, Treboeth, Fforestfach, Ravenhill, Brynhyfryd, Manselton, Gendros and Penlan.
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The Penderi Cluster is made up of six general practices working together with partners from key Local Authority Departments such as Social Services and Poverty and Prevention, the Voluntary Sector, Community Pharmacies, Dentists and Optometrists and the wider ABMU Health Board. Practice populations ranging from 2091 to 8334, amounting to a cluster total of 38,122 (July 2018 data).
Clusters across the area have agreed that they aim to work together in order to:
Prevent ill health enabling people to keep themselves well and independent for as long as possible Develop the range and quality of services t hat are provided in the community Ensure services provided by a wide range of health and social care professionals in the community are better co-ordinated to local needs Improve communication and information sharing between different health, social care and voluntary sector professionals Facilitate closer working between community based and hospital services, ensuring that patients receive a smooth and safe transition from hospital services to community based services and vice versa
Through the delivery of their plans they work to meet the Quadruple Aims set out for Health and Social Care Systems in Wales in ‘a Healthier Wales’ (2018):
improved population health and wellbeing better quality and more accessible health and social care services higher value health and social care a motivated and sustainable health and social care workforce
The Cluster will work collaboratively with Public Health to achieve the outcomes noted in the ‘Burden of Disease’ Action Plan by adopting the five ways of working as outlined in the Wellbeing of Future Generations Act. (Long term, integrated, involving, collaborative, prevention)
2.1. Swansea wide ‘Headline’ Information
Population: 242,400. High concentrations of population in and immediately around the City Centre, the adjacent wards of Cwmbwrla and uplands (6,800 people per square km, the highest density in the county) and also in Townhill and Penderi
Population has steadily grown between 2001 and 2015. Main driver of population growth in Swansea has been migration. Recorded live births has steadily risen since 2001 and number of deaths have fallen.
Life expectancy in Swansea is increasing: Average life expectancy for males is 78 (Wales 78.5) and 82.4 for females (Wales 82.3). This will impact significantly on the provision of health, social care and other public services in Swansea
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Projected population Change: Welsh Government’s latest trend based population projections suggest that Swansea’s population will grow by 9% (21,600 people) between 2014 and 2039
2011 Census suggests that 14,326 people in Swansea were from a non white ethnic group: 6% of the total population and 20,368 (8.5%) of Swansea’s Population were non white British. (above the Wales average (6.8%). Census data (2011) suggests the largest non white ethnic groups are: Chinese 2,052 (0.9%), Bangladeshi 1,944 (0.8%), Other Asian 1,739 (0.7%), Black African 1,707 (0.7%), Arab 1,694 (0.7%)
Welsh Language : Proportion of people able to speak Welsh in Swansea decreased from 13.4% (28,938) in 2001 to 11.4% (26,332) in 2011. A fall of 9% despite an increase in population.
2.2 Cluster Specific Information
Health and Attainment of Pupils in Primary Education Network (HAPPEN) Established in April 2015, HAPPEN focuses on children in Swansea Schools aged 9-11 years who complete health and wellbeing assessments as part of the Swan Linx Project. Data is collected on body mass index, fitness, nutrition, physical activity, sleep, wellbeing, concentration and children’s recommendations on improving health in their area. Blaenymaes and Portmead schools, (two of the Primary Schools within the Network) have undertaken the study within the last two years, areas of interest are shown below:
Blaenymaes % Portmead % Swansea % Sedentary Screen time for 2 hours or more 41% 38% 31% a day 5 Portions of Fruit and Veg a day 17% 24% 27% At least 3 take aways a week 17% 16% 18% Physically active for 1 hr or more a day 24% 14% 24% Happy with family 96% 93% 94% Happy with Life as a whole 94% 81% 91%
2.3 Our Local Health, Social Care and Wellbeing Needs and Priorities
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Information has been collated on a wide range of health needs using the most up to date information available within the Penderi Cluster area in order to support the development of the focus areas for this plan.
Key Population Features Cluster Features Population & Community Assets Resident population: 31,900 ( Community Area Profile:Source Mid 2016 rounded estimates ONS) 18 Lower Super Output Areas in the cluster areas. Smallest land 6 GP Surgeries Community Farm located area but highest population density of the cluster areas in Swansea close to Penderi practices. (Community Area Profile) 4 Dental Practices 32.8% of residents are under 24. (Swansea: 31.3%) Parks and Green Spaces 8 pharmacies 8.7 % of residents are 65-74 (Swansea: 10.4%) and 7.5% are 75+ including Blaenymaes multi (Swansea 8.9%) 5 Opticians Use Games Area, Penlan Nearly 50% of patients are living in the 20% most deprived areas Leisure Centre, Ravenhill, 9 Primary schools & 2 Cwmbwrla , Treboeth and (WIMD 2014 revised) Secondary Schools 35.2% of the population live in social rented accommodation from Hafod parks council or RSL/HA). Swansea average is 19.2%. (Swansea 38,122 patients registered- High levels of third Assessment of Local Wellbeing 2017) majority of list sizes increasing sector/external partner Number of people in non white ethnic groups 5.1% .(Swansea High service need for patients involvement in Cluster average 6%) (Swansea Assessment of Local Wellbeing 2017) living in a care home network Highest percentage of lone parents in Swansea 16.7% Swansea specialising in mental health Community Centres (x6) average: 11.7%. (Community Area Profile 2017) and previous drug abuse Libraries (x2) 36.7% of 16-74 year olds are 'economically inactive'. (Swansea: 37%) Two women's refuges within Major employers in the 35.6% of the population aged 16+ have no qualifications . This is the the network (for women and Cluster: City and County of highest level in Swansea. Swansea average is 23.9%. (Swansea children who are victims of Swansea (Schools and Assessment of Local Wellbeing 2017) domestic abuse) depots), First Cymru, Cwmdu 26.3 % of the population have a long term health problem or Industrial Estate, part of disability. This is the highest percentage in Swansea. (average is Swansea West Industrial 23.3%.) (Swansea Assessment of Local Wellbeing 2017) Estate
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Service demands Health Profiles Other Key Influencing High levels of patients who smoke 7,420 , 24.7% of the cluster population (PHW Data 2016/17) Penderi has the second highest Features proportion of patients attending A&E out of all the Swansea Clusters. Average number of lung cancer cases per annum is 32. This is the Between 1st Sep 2017 and 31st Aug Swansea Local Development Plan - highest rate out of the five clusters in Swansea.'Lung cancer 2018, 11,846 patients attended A&E. 3,175 new homes proposed in cluster incidence is higher in the most deprived areas of all ABMs clusters Rate 155.88 per 1000 (ABMU HB data) area with with varying deprivation gaps' (CGP Cluster Lung Cancer Profile ABMU HB Sept 2015) Between September 1st 2017 and 31st Hafod Air Quality Management Action Third highest network for COPD in 2017 956 (6.2%) of patients are August 2018 the attendance rate for Plan declared in Lower Swansea Valley on the disease register. (Swansea average: 5.6%) OoH was 92.18 per 1000 people, the highest rate in Swansea. Uptake for scheduled childhood immunisations by 4 years is 84.5% Public Service Board: Local Wellbeing against the Welsh Government target of 95% Plan Focus; An average of 18.6 patients per month attended the Help Me Quit Service Uptake on Bowel screening 47.4% . Target 60% (PHW offered in practices between April Early Years: Making Sure Children have Data2016/17) 2017 and March 2018. Highest number the best start in Life Uptake on Cervical Screening 75.3% . Target 80% (PHW Data of attendees (30) was in January 2016/17) Live Well. Age Well-Making Swansea a place to live and age well Uptake on AAA screening 75.9%. Target 80%. (PHW Data High levels of low level mental health 2016/17) issues evidenced by Social Presecribing Working with Nature-Improving initiatives including CAB and Primary health,supporting biodiversity and Uptake on Breast screening 71.3%.Target 70% (PHW Data Care Children and Family Wellbeing rediucing our carbon footprint 2016/17) Service and anecdotally by GPs Strong Communities-Supporting Communities to promote pride and Penderi Children and Young People Flu Immunisation Uptake (PHW Data 2017/18): belonging Mental Health consultation identified Patients 65y and over: 66.6% (ABM 68.2%/ Swansea 67.4%) that 75% of respondents needed PSB Aims to make sure all services Patients under 65y at risk 49.9% (ABM 46.7%/Swansea 46.5%) support for mental health issues before work together by sharing resources, Patients under 65y at risk (Respiratory): 52.4% (ABM: 47.2%/ the age of 17, 40% needed support assets and knowledge between 12-16 years and 35% needed Swansea 47.3%) -Wellbeing of Future Generations support under the age of 11 Children aged 2&3 Years 45.6% (ABM 49.1%/Swansea 47.4%) (Wales) Act
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2.4 Disease Register Information
Disease Penderi Register Cluster Trend Swansea % ABMU % Register Total 2018 (%) Cancer 887(2.3%) (2.7%) (2.9%) Practice Variations. Lowest % in Swansea, 2009:1.5%, 2018: 2.3% Dementia 202 (0.5%) (0.7%) (0.7%) Cluster % decreased in last 2 years. Lowest % in Swansea Mental Health 430 (1.1%) (1.1%) (1.1%) Practice Variations 2009: 0.9%, 2018:1.1% Obesity 4148 (10.9%) (9.1%) (10 %) 2nd highest % out of Swansea Clusters, 2009 8.8%, 2018: 10.9% (Decrease 2012-2017) Diabetes 2449 (6.2%) (5.6%) (6.4%) Practice variations but highest % in Swansea, 2009: 5.1%, 2018: 6.4% COPD 956 (2.5%) (1.9%) (2.2%) Third highest number/cluster in Swansea. Significant practice variations. 2009:2.5%, 2018:2.5% Epilepsy 330 (0.9%) 0.8% 0.8% Highest % out of Swansea Clusters Learning 213 (0.6%) 0.4% 0.5% Highest % in Swansea Disabilities Stroke 812 (2.1%) 2.1% 2.3% Highest % in Swansea
2.5 Antibiotic Prescribing Levels
Items % Variation Items Difference Items Apr 17 - Mar 18 Items Apr 16 - Mar 17 25,474 25,978 -1.94% -504
(With regard to antibiotic prescribing levels nationally there was a 2.2% reduction for the period noted in the table above)
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3. Strengths Weaknesses, Opportunities and Threats (SWOT) Analysis Penderi Cluster
Strengths Weaknesses Investment in innovative projects Lack of time to develop initiatives Open to new ideas and an 'upstream' approach Substantial Cluster- wide sustainability issues Comprehensive approach to PLTS Staff working to full capacity Strong links with Third Sector and other external partners Difficulty regarding recruitment and retention of GPs Development of key Social Prescribing initiatives (Child and Family Difficulty sourcing locums Wellbeing Service, Carers Helpdesks, Asylum Seeker Support, CAB No 'body' with which to draw in additional funds- no ability to Outreach service) expand rollout New practice developments in area eg: Brynhyfryd Recognising of cluster population needs and taking a preventative approach to support these Cluster SWOT Opportunities Analysis Further develop social prescribing/support within the network Threats Re-evaluation of use of limited resources Proposed housing developments in the network area leading to an Further strengthen links with third sector organisations and external additional 3,175 houses being built partners Potential list closures could impact negatively on other practices Share with other clusters/develop mutually beneficial links 18/19 QoF may result in lower levels of engagement in Cluster work Improve communication across the cluster GP retirement and recruitment issues Use mobile technology to help patients manage conditions Staff shortages in other areas eg: Central Hub Support key practice issues: high levels of mental health issues/substance misuse/asylum seekers and speakers of other Staff morale and wellbeing languages Cluster work programmes dependant on continuation of Welsh To support staff/GP resilience via PLTS Government annual funding To further enhance MDT across Cluster to support sustainability
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4. Cluster Vision
In May 2018, the Penderi Cluster Network jointly agreed a Cluster Vision for the next three years. The Vision sets out how this Cluster sees its role in providing health, social care and wellbeing with and for the population of the Penderi area and its practices.
“The members of the Penderi Cluster have a vision to care for the unique health and wellbeing needs of its patients and citizens in the most effective way possible. In recognition of its particular population needs, it will also work together to create an innovative culture of enabling long term change by taking a preventative approach to tackling ill health and its contributing factors”.
5. Penderi Cluster Practice Priority Issues
Practices have expressed a range of areas which are a priority for them in delivering a sustainable and effective primary care service. These issues have also been taken into account in developing the Penderi Cluster Plan.
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Our Cluster Plan
Strategic Aim 1: To understand and highlight actions to meet the needs of the population served by the Cluster Network with a preventative approach
Our three year focus:
To deliver services based on specific population health and social care needs in the cluster which has the highest deprivation levels in Swansea to inform the planning of services in the network. In recognition that Penderi has high levels of deprivation the health and wellbeing focus areas for 2018-21 are: Children and Families/Obesity and Diabetes and Smoking The focus areas will be addressed by further developing and expanding preventative work programmes and improving health literacy based on patient feedback to support key patient groups/vulnerable patients.
No What action will be taken Who is When will it What will success look Current position RAG responsible be completed like? What will the Rating for delivering by outcome be for patients? 1.1 Obesity: GPs March 2019 Reduced levels of obesity Develop resources that can be used with Practice and ongoing in children and young parents Managers people resulting in greater ABMU HB wellbeing 1.2 Consider delivering talks to parents on TBC March 2020 Preventative approach, Links with parents and schools healthy eating/physical activity in early intervention, need to be enhanced community/school settings 1.3 Develop a ‘resource pack’ that can be SCVS, HB – July 2019 Clinicians able to signpost Requirement for clarity on used to effectively signpost children and Primary Care or refer to the most services available. young people to services that can help- and Mental appropriate service. eg: Hwb Abertawe Health Units, Patient able to access Practice support suitable for their Managers needs in a timely fashion. 1.4 Consider developing cluster initiatives to All Cluster July 2019 Clinicians able to refer to Proposal has been put to the support increasing physical activity levels members more timely closer to Cluster by Cwmfelin Medical home services. Centre on increasing Physical Activity levels in children and
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young people. Cluster to consider this proposal 1.5 Make use of intelligence/data gathered HB, PHW, Ongoing More targeted Lack of local information around by HAPPEN Programme to inform Cluster interventions provided. children and young people obesity development of cluster initiatives Those a greatest need of and contributory lifestyles preventative interventions able to access 1.6 Links with specialist consultant in Cluster, Chris Dec 2018 Cross system input into Working links have been made Paediatrics re advice/clinical input linked Bidder most effective with Paediatric Consultant who to childhood diabetes interventions available has attended PLTS sessions and within Primary Care. More offered support/advice on consistent provision for individual cases as appropriate. patients. 1.7 Monitor referrals to Primary Care PCCFS lead, Ongoing 2019 Enhanced use of delivery Children and Family Wellbeing Team BSM, PHW of PC Children and regarding issues linked to diet and Families Service obesity and look at effect of intervention on reducing obesity 1.8 Smoking: GPs March 2019 Reduced levels of Encourage patients to attend stop Practice and ongoing smoking across the smoking clinics Managers cluster (from 24.7% to PHW 23% by October 2019). Resulting in better health outcomes and wellbeing 1.9 Practices to hold ‘Help Me Quit’ Clinics ‘Help Me Quit’ Service is available on a regular basis in some practices across the network.
1.10 Publicise service at key points of the PHW/Cluster Jan 2019, 20 year eg: New Year/January campaigns and 21
1.11 Health Literacy: SCVS March 2019 Improved Health Literacy SCVS drafting questionnaire to - Health Literacy questionnaire among patient population. gather patient feedback on what and focus group to be Following patient could be done differently to help undertaken during 2018/19 by feedback changes to be improve health literacy. SCVS to inform planning going made with regard to Questionnaire will be used with forward into 2020 and 2021 communication of existing groups in the Cluster information (both written linked to Social Prescribing
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and verbal) to patients. network ie: Carers/ Parents/ Resources and new ways Asylum Seekers and Refugees of working will be co produced resulting in improved self care and better understanding of health conditions and how to manage them
Strategic Aim 2: To ensure the sustainability of core GP services and access arrangements that meet the reasonable needs of local patients including any agreed collaborative arrangements
Our three year focus:
Expand and pilot MDT developments to meet workforce needs of the Cluster. Implement sustainable, evidence led, robust MDT for the cluster by 2021 Explore collaborative working arrangements eg: sharing workflow information Establish a cluster social prescribing programme to alleviate pressure on core services
No What action will be taken Who is When will it What will success look Current position RAG responsible be completed like? What will the Rating for delivering by outcome be for patients? 2.1 Develop collaborative working GPs March 2019 Improved shared arrangements and share Practice and ongoing understanding of Cluster Cluster have agreed to meet information across practices eg Managers sustainability issues. before Christmas 2018 for a ‘time workflow ABMU HB Cluster to agree best use out’ session to discuss planning of shared resources to and ideas linked to sustainability Cluster to set aside time to discuss ensure sustainability of all going forward and consider sustainability of network practices practices moving forward Robust plans in place across cluster to meet sustainability needs 2.2 Expand MDT across the Cluster GPs March 2019 – Cluster to pilot on site Cluster has agreed to progress -Introduction of pilot physiotherapy Practice March 2021 physiotherapy sessions Physiotherapy pilot. HB currently initiative in 2018/19 Managers supporting sourcing
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ABMU HB with remaining cluster Physiotherapists who might be funds able to deliver sessions.
2.3 Continue to expand and further GPs March 2019 – Preventative approach SCVS is holding meetings to allow develop Social Prescribing Practice March 2021 strengthened by further Penderi Social Prescribing initiatives to alleviate pressure on Managers development of social initiatives to meet and discuss core services and adopt an SCVS prescribing network service offered and cross refer ‘upstream’ approach ABMU HB across the cluster. This patients as appropriate. -Children and Family Wellbeing will result in increased Service levels of wellbeing and Cluster pharmacist to develop -Carers contribute to an referrals to Social Prescribing for -CAB improvement in low level patients seen. -Asylum Seeker Support mental health issues - Other links and initiatives to be across the cluster SCVS planning to develop a developed eg: Community Farm ‘ready reckoner’ for all social -Links with HWB Abertawe prescribing initiatives that are -Develop Social Prescribing links delivering across the cluster that with Cluster Pharmacist for onward can be used by GPs as an aide referral of patients memoire of what is available when -Enhance links with Local Area seeing patients. Coordination Programme
Strategic Aim 3: Planned Care - to ensure that patient’s needs are met through prudent care pathways, facilitating rapid, accurate diagnosis and management and minimising waste and harms. To highlight improvements for primary care/secondary care interface.
Our three year focus:
Reduction in antibiotic prescribing with particular reference to UTIs To continue to promote screening with patients as appropriate To develop positive working links with Paediatrics to help raise awareness of specific clinical issues related to children and young people and improve communication with secondary care
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No What action will be taken Who is When will it be What will success look Current position RAG responsible completed by like? What will the Rating for delivering outcome be for patients? 3.1 Reduction in Antibiotic Prescribing: Cluster March 2019 and Reduction in Comparing the years 16/17 and Pharmacist ongoing prophylactic prescribing 17/18 antibiotic prescribing levels Cluster Pharmacist to initiate reduction GPs levels resulting in better have reduced (1.94%). There is in antibiotic prescribing across all outcomes for patients a need to further reduce this practices with a focus on prophylactics and cost savings, long level. In the same period, 3.2 Deliver PLTS on reduction of antibiotic BSM Nov 18/Jan 19 term stewardship of nationally antibiotic prescribing prescribing (prophylactics)-link to be antibiotics levels fell by 2.2% made with Avril Tucker 3.3 Link with ED Clinicians over prescribing May 2019 Antibiotic prescribing Penderi has high rates of OoH of antibiotics to reduce tendency for rates reduced at ED and A&E attendances. GPs them to be the first option point of access, report that antibiotics prescribed reduction in ongoing P in A&E and OoH on a more Care prescribing as a regular basis. result 3.4 Practices and Clinicians to play an Practice March 2019 and Screening widely Screening opportunities are active role in promoting screening Managers ongoing promoted and widely promoted across the opportunities to patients through: GPs information visible Cluster. Based on PHW figures across all practices for 2016/17 screening -Up to date relevant information easily resulting in higher levels engagement rates are below accessible of patients engaging target -Promotion on practice web sites and TV with screening services. screens Increased early -Link with PHW on best way to follow up intervention resulting in on non-attendees better patient outcomes.
3.5 To develop positive working links with Cluster Lead March 2019 and Easy and quick access Paediatric Consultant to attend a Paediatrics GPs ongoing to expert advice for future session to deliver clinical -Develop e-mail advice line for fast Practice Penderi GPs with regard input on Addison’s Disease. expert guidance when appropriate Managers to Paediatric concerns. -Consultant to attend Penderi PLTS GPs updated on clinical sessions on a regular basis to update on pathways and current relevant issues pertinent to Children and clinical data and young people eg: Childhood Diabetes, information regarding Addisons disease etc paediatrics
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Strategic Aim 4: To provide high quality, consistent care for patients presenting with urgent care needs and to support the continuous development of services to improve patient experience, coordination of care and the effectiveness of risk management. To address winter preparedness and emergency planning
Our three year focus:
Continue to educate patients in how to manage self-care and identify the most appropriate place to receive treatment To reduce any inappropriate use of A&E and GP OoH by Penderi Patients,with a focus on attendance by children and young people Ensure advanced cluster planning takes place related to ‘winter preparedness’ including flu vaccinations and immunisations
No What action will be taken Who is When will it What will success look Current position RAG responsible be completed like? What will the Rating for delivering by outcome be for patients? 4.1 Develop educational approach to GPs July 2019 Patients aware of when to Penderi has high rates of A&E inform patients on when to access A&E contact A&E and OoH. and OoH attendances. and OoH: Practice Contacts to these Develop practice leaflets that can be Managers services will be shared with patients and cascaded via appropriate Midwives/Health Visitors/Social Prescribing networks/Colleagues in A&E for onward distribution
4.2 Further research and understand data June 2019 and Reduction in numbers of As above linked to frequent attendees by linking ongoing patients attending A&E with A&E and engaging with OoH service. 4.3 Target young families with regard to self- Sept 2019 Reduction in numbers of As above care via leaflets/resources and talks to be patients attending A&E delivered to family/parenting groups and and engaging with OoH in schools/E-bug school programme re: service. minor illnesses 4.3 To ensure effective planning is in place for GPs Sept /0ct 2018 High levels of patients Cluster Flu Vaccination Figures the winter season to ensure continual and ongoing including older and based on PHW Data 2017/18 increase in uptake of Flu Vacs and Practice housebound patients,at included in Health Profile section advanced promotion of self care Managers
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- Practices to host flu parties risk patients and children - Vacs for Housebound patients to immunised against flu. continue Patients ‘health literate’ - Publicity/self care info for patients with regard to myths including myth busting surrounding flu and - Consider other methods and channels actively seeking flu vacs. of publicising/promoting the benefits of the flu vacs
Strategic Aim 5: To develop the Cluster as a structure for delivery of identified priorities.
Our three year focus: Enable cluster to reach full maturity against key criteria below Expand opportunities for innovative partnership working to effectively and innovatively support patient needs Access potential external funding streams to bolster existing cluster funds Consider benefits to cluster of becoming a formal collaborative entity
No What action will be taken Who is When will it What will success look Current position RAG responsible be completed like? What will the Rating for delivering by outcome be for patients? 5.1 Identify the suitability of an appropriate Cluster Lead May 2019 Best support possible in Cluster experiencing high levels of method of formal collaboration to Lead GPs place for Cluster sustainability issues with need to develop wellbeing for the cluster and PMs, HB practices, enabling better maximise cluster ability to support seek cluster ratification and continued access for practices. Establish a working group to develop patients. and implement if required Cluster members able to deliver and provide clarity regarding roles and responsibilities. 5.2 Allocate protected time for Lead GPs to Cluster Lead Ongoing, Cluster programmes able Cluster Lead allocated ½ day per further develop innovative ideas and to Lead GPs commencing to be delivered more week to deliver all cluster work, ensure cluster actions are met PMs, HB Jan 2019 quickly, time for cluster including main GP lead for Early lead to further consider Years flagship programme, strategic direction. additional capacity required.
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5.4 Establish business planning cycle for Cluster Lead March 2019 More vigorous approach In place on an ad hoc basis in cluster to prioritise cluster projects and Lead GPs to deliver cluster strategic relation to cross cluster issues. planning spend PMs, HB direction and minimising likelihood of slippage. ensuring most effective use of funding. 5.5 Establish cluster communications Cluster Lead June 2019 Strategic stakeholders Communications made on strategy, identifying key stakeholders to Lead GPs aware of key cluster opportunistic basis eg via WG influence to maximise impact, including PMs, HB programmes. communications scheme through sharing best practice delivered in Health Board. Penderi Cluster Cluster members better aware of outcome from use of time and resources. 5.6 Ensure Cluster compliant with GDPR for Cluster Lead March 2019 All staff will receive GDPR Training resource to be identified cluster based /delivered activity Lead GPs training PMs, HB 5.7 Review of Cross Cluster IT, Estates Cluster Lead Dec 2019 Better use of current Clear understanding of resources Infrastructure to meet aims Lead GPs resources across the to be considered in planning of PMs, HB cluster services. 5.8 Implement mobile technology to support Cluster Lead Dec 2019 Delivery of services To be scoped cluster working Lead GPs effectively and efficiently PMs, HB using modes of technology
5.9 Enable practice and team time to collate Cluster Lead March 2019 Demonstration of Practices identifying time within and set out data for external evaluation Lead GPs effectiveness of Cluster current constraints. PMs, HB programme.
More prudent commissioning of services. 5.10 Develop potential for planning cluster Cluster Lead Ongoing To have clear aims, Cluster vision set, priority areas of spend across 3 year period Lead GPs objectives and vision of focus. 18-24 mth spend plans in PMs, HB areas in which Penderi place. wish to implement change and develop existing
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services to enable planning and resource identification 5.11 Identify and secure additional funding Cluster Lead Ongoing External funding available Little leverage of additional streams Lead GPs for the cluster to deliver funding and resources currently PMs, HB services meeting its done. identified priorities
5.12 Ensure the Cluster addresses population Cluster Lead March 2020 Cluster using Patient panels attempted. needs by: Lead GPs benchmarking in relation - Ensure that the public and PMs, HB to unscheduled Care, Patients not extensively involved service users are involved in the Paediatrics. in design and delivery of services design, planning and co- though feedback from evaluation production of local services and is taken into account in improving pathways service delivery. - Undertake continuous Benchmarking commenced in benchmarking between cluster Clinical Priority Areas in 17-18. practices to address any variation 5.13 Integration and Partnerships Cluster Lead May 2019 Cluster partners Code of Conduct required. - Draw up a code of Conduct Lead GPs understand their between cluster partners and PMs, HB respective roles Local assets not extensively organisations utilised on a Cluster basis - Understand local assets and Patients and citizens how to access local services aware of local assets and benefits to them of their use
Strategic Aim 6: Other Cluster and area specific issues
Our three year focus: To continue to improve multi agency mental health services for adults children and young people with a quality improvement approach
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No What action will be taken Who is When will it What will success look Current position RAG responsible be completed like? What will the Rating for delivering by outcome be for patients? 6.1 To continue to improve access to PM’s March 2019 Easier and faster access SCVS to develop flow charts/pack mental health services GPs and ongoing for patients to relevant that can be used by GPs in - Development of ‘ready reckoner’ SCVS mental health services Primary Care outlining referral for mental health referrals for routes and sources of support. GPs Patients accessing the Pack to be updated on a cyclical - Development of pack outlining right service at the right basis service provision for use by GPs time - Regular meetings of Social Cluster able to discuss barriers Prescribing organisations in the GPs comfortable and and possible ways forward Penderi Network to facilitate knowledgeable about following CAMHS presentation. cross referrals when appropriate local referral routes and - Give timely and appropriate mechanisms CAMHS developing ‘helpline’ and feedback to mental health developing improved referral services to highlight issues in timescales to Primary and general practice to facilitate Secondary CAMHS effective solutions 6.2 Create links with City Farm - offering PMs, SCVS, March 2019 Patients and residents Local assets not extensively volunteering and wellbeing opportunities HB able to benefit from local utilised on a Cluster basis for all people in the Network asset in relation to wellbeing/social isolation. 6.3 Support the mainstreaming of services Cluster Oct/Nov 2018 Services mainstreamed Pharmacy outline case via the business case application Development and Cluster funds summarised for consideration by process through: Managers, released where relevant ABMU Strategy and Finance - ‘Balancing the System – shifting Cluster Lead Depts. resources from secondary to primary care’ for: Physiotherapist preferred option -Mental Health Services for Tier 0 model being costed - Pharmacist Provision - Physiotherapy on a cluster basis
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6. Cluster Finance Statement
The Penderi Cluster has a financial allocation from the Welsh Government of £171, 472. In addition Clusters have access to other funding streams such as through the Health Board delivered PMS+ scheme.
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